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Joseph Lamacchia v. Michael Astrue

April 9, 2012


The opinion of the court was delivered by: McVerry, J.


I. Introduction

Joseph Lamacchia ("Plaintiff"), brought this action pursuant to 42 U.S.C. § 1383(c)(3) for judicial review of the final determination of the Commissioner of Social Security ("Commissioner"), which denied Plaintiff's application for supplemental security income ("SSI") under Title XVI of the Social Security Act, 42 U.S.C. §§ 1381-1383f.

II. Background

Plaintiff was 34 years old on the date his application was filed, making him a younger person whose age does not affect his ability to adjust to other work pursuant to 20 C.F.R. § 416.963. He is a high school graduate, capable of communicating in English, with three years of vocational training as a mechanic. (R. 28, 122). He has past relevant work experience as an auto mechanic and kitchen installer. (R. 118). The vocational expert who testified at Plaintiff's administrative hearing described the job of auto mechanic as skilled work performed at a medium level of exertion and the job of kitchen installer as low-level skilled worked performed at the heavy exertional level. (R. 23). Plaintiff has not engaged in substantial gainful activity since the alleged onset date.

A. Medical Evidence

The record reflects that Plaintiff has a history of chronic back pain, which was treated with opioids, prior to the alleged onset date of June 10, 2007. However, there is no medical documentation in the record prior to March 2, 2008. On that date, Plaintiff was apparently in a car accident, after which he was transported by ambulance to Jefferson Regional Medical Center ("Jefferson"), complaining of pain in his head, neck and back. (R. 150). Plaintiff left the hospital before being examined. (R. 151).

On June 26, 2008, Plaintiff was again taken by ambulance to Jefferson after he experienced a seizure while driving. (R. 205-06, 215). In the ER, he reported that he had been taking Xanax to treat anxiety but had been weaning himself off of it in the preceding two weeks. (R. 199). He also reported that he had stopped taking medications for his chronic back pain about a month prior to presenting to the ER. (R. 199). On examination by Sundeep Ekbote, M.D., Plaintiff had tenderness over the lower thoracic and upper lumbar regions, but overall was not in acute distress. (R. 200). Dr. Ekbote diagnosed Plaintiff with a seizure, and noted that he had history of substance abuse. (R. 204). Further, because the seizure appeared to be related to withdrawal, Dr. Ekbote recommended that Plaintiff be admitted to the hospital. (R. 203).

After being admitted, Plaintiff underwent a consultative examination with Eric Chamberlin, M.D., a spine specialist, during which Plaintiff stated that he had been taking "heavy dose narcotics" for the past two years. (R. 225). According to Dr. Chamberlin, Plaintiff appeared pleasant and was not in acute distress. (R. 225). Further, although he had tenderness in his lower thoracic and upper lumbar spine, he experienced no pain while in motion. (R. 225). Dr. Chamberlin decided to prescribe Plaintiff a back brace. (R. 219-21, 226). In addition, like Dr. Ekbote, Dr. Chamberlin suspected that Plaintiff's seizure was due to tapering of benzodiazepines, i.e. anti-anxiety medications.

(R. 225).

Plaintiff also underwent a neurological consultation on June 26, 2008. (R. 217).

John B. Talbott, M.D., conducted the consultation and recorded in his notes that Plaintiff reported experiencing thoracolumbar pain. (R. 217-18). Dr. Talbott also noted that Plaintiff's urine tested positive for anti-depressants. (R. 217). He concluded that Plaintiff may have suffered a withdrawal convulsion, which apparently resulted in the car accident, but he also noted that he "question[ed] this man's credibility" and was "not sure if anything he says is entirely correct." (R. 218). Nonetheless, Dr. Talbott ordered Plaintiff to not operate a vehicle until he was seizure-free for at least six months. (R. 218).

At Dr. Talbott's recommendation, Stephen Patternac, M.D., a drug and alcohol addiction specialist, also examined Plaintiff. (R. 218, 219, 222-23). Although Dr. Patternac suspected that Plaintiff had experienced a withdrawal seizure, he noted that he had seen patients discontinue the level of Xanax that Plaintiff stated he was taking without suffering any problems. (R 222). He also indicated in his notes that the prescription pain reliever Ultram could produce seizures if used to excess. (R. 222).

Over the course of his hospital stay, Plaintiff underwent several tests and x-rays. First, a head CT scan returned negative results, and a brain MRI was unremarkable. (R. 239, 250). Next, x-rays taken on June 27, 2008 showed 50 percent compression of T12, a spinal nerve of the thoracic segment. (R. 236, 244, 247-48). The following day, Plaintiff had thoracic spine and lumbar MRIs taken. (R. 241-42, 253-54, 274). The thoracic spine MRI showed a compression fracture of the T12, with mild to moderate central spinal stenosis. (R. 241-42). The lumbar MRI revealed anatomical alignment and pristine vertebral disks, with a stress fracture in one of the vertebrae. (R. 241-42). Finally, on July 2, 2008, thoracic spine and lumbar spine x-rays were taken, showing anterior wedging of T12, but a normal lumbar spine. (R. 243-44). That same day, Plaintiff was discharged with a diagnosis of a compression fracture of T12 and seizure disorder resulting from benzodiazepine withdrawal. (R. 197-98).

On August 14, 2008, Plaintiff had a follow-up with Dr. Chamberlin. (R. 260). At that time, he had been wearing his back brace for about six weeks. (R. 260). Because Dr. Chamberlin was not satisfied with Plaintiff's progress with the back brace, he told Plaintiff that he should consider having surgery. (R. 260).

Later in August, Plaintiff began treatment with Rodney B. Dayo, D.O, a pain management specialist. (R. 276). At their initial visit, Dr. Dayo recorded in his notes that Plaintiff did have a compression fracture. (R. 276). However, he also noted that he was "concerned of [Plaintiff's] integrity because he was a former patient of Dr. Cawog in Westmoreland County." (R. 276). As a result, Dr. Dayo decided not to place Plaintiff on a narcotic regimen, noting that Plaintiff may respond to Calictonin and NSAIDS better if his "pain is real." (R. 276).

On August 19, 2008, Plaintiff underwent back surgery with Dr. Chamberlin. (R. 157, 162-63, 179, 264, 261-62, 267-68). His post-operative pain was managed with Oxycontin, Roxicode, and Dilaudid, each of which was prescribed by Dr. Dayo. (R. 262). Dr. Dayo planned to discontinue these medications in four to eight weeks, noting that "[t]here are some questionable things that have gone on in recent visits that make us extremely hesitant to place him on a long term narcotic regimen." (R. 262). Plaintiff was discharged on August 24, 2008 and directed to avoid heavy lifting, pushing, or pulling.

(R. 262).

Plaintiff followed up with Dr. Chamberlin on September 3, 2008, at which time he was "doing extremely well." (R. 259). According to Dr. Chamberlin's notes, Plaintiff "look[ed] 100% better than he did preoperatively. (R. 259). He was "up straight, [and] walking around at ease." (R. 259). Dr. Chamberlin further noted that Plaintiff's incision had healed, that he had 5/5 strength bilaterally in his lower extremities, and that his x-rays were "perfect." (R. 259). Later that month, Plaintiff began to wean off of his pain medications, after consulting with Mark G. Boles, M.D., a third pain-management specialist. (R. 315).

Plaintiff next saw Dr. Chamberlin on October 8, 2008. (R. 258). Dr. Chamberlin again noted that Plaintiff was progressing very well. (R. 258). His x-rays looked "outstanding," he walked "fine," and he was neurologically intact. (R. 258).

On November 24, 2009, Mary Ellen Wyszomierski, M.D., a state agency physician, reviewed Plaintiff's file and assessed a fracture of T12 and lumbar spondylosis. (R. 281). Based on her review of all of the medical records, particularly Dr. Chamberlin's notes indicating that Plaintiff was doing well and had recovered strength in his lower extremities, Dr. Wyszomierski concluded that Plaintiff had the residual functioning capacity for light work with occasional postural maneuvers. (R. 282-86).

She also opined that Plaintiff had the following limitations: he should avoid concentrated exposure to extreme cold and wetness and moderate exposure to vibration and hazards.

(R. 284). Further, she opined that Plaintiff would make a satisfactory recovery before the completion of the 12-month period required for a finding of disability under the Act. (R. 287).

Two days later, Manella Link, Ph.D., completed a Psychiatric Review Technique form, in which she indicated that Plaintiff's pain disorder was not severe. (R. 288-300). She found that Plaintiff had no restriction of activities of daily living; no difficulties in maintaining social functioning; and mild difficulties in concentration, persistence, and pace. (R. 298). She also noted that Plaintiff was not receiving treatment from any mental health treating sources. (R. 300).

On December 4, 2008, Plaintiff saw Dr. Talbott in order to complete the necessary paperwork to reapply for a driver's license. (R. 301-03). On examination, Dr. Talbott found that Plaintiff was able to walk normally and had not experienced any additional seizure activity for six months, so he completed the paperwork to allow Plaintiff to reapply for a license. (R. 301-03).

Throughout December 2008 and January 2009, Plaintiff continued to see Dr. Boles, who reported that Plaintiff was progressing well. (R. 312-13). Dr. Boles refilled Plaintiff's medications on December 31, 2008. (R. 312). On January 13, 2009, however, Dr. Boles refused to refill Plaintiff's Dilaudid prescription after Plaintiff attempted to renew it too early. (R. 312).

During an appointment with Dr. Chamberlin on January 23, 2009, Plaintiff again appeared to be doing well. (R. 304). Although he complained of sciatic pain in his left leg, he displayed 5/5 strength and no nerve tension signs. (R. 304). His x-rays, however, did show a spondylolyosis and a slight spondylolisthesis at L5-S1. (R. 304). According to Dr. Chamberlin's notes, Plaintiff could have opted to have another surgery, but Dr. Chamberlin recommended against it because so little time had passed since Plaintiff's first procedure. (R. 204). Furthermore, Dr. Chamberlin noted that Plaintiff was on "a lot of pain medication," and refused Plaintiff's request to prescribe any additional pain relievers because Plaintiff was already under the care of a pain-management specialist.

(R. 304). Instead, Dr. Chamberlin prescribed physical therapy. (R. 305).

On January 28, 2009, Plaintiff saw Dr. Boles, whom he told he "needed" pain medications reportedly for a "new fracture" in his lower back. (R. 304). Plaintiff also reported to Dr. Boles that he and Dr. Chamberlin were discussing additional surgery. (R. 311). Dr. Boles refilled Plaintiff's ...

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